Friday, October 22, 2010

Wrong-site wrong-patient procedures

Design Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008...

Results A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-siteoccurrences.

These were in just one state, mind you.

What do these data say about Joint Commission's universal protocol? On the one hand, had it been adhered to fully a number of occurrences could have been averted (72% of instances were associated with failure to perform a time-out). On the other hand, looking in the body of the paper, there was no decrease in incidence over the years following the rollout of JC's protocol in 2004.

Skeptical Scalpel, who weighs in here, seems to share my annoyance about distorted reporting of medical issues by popular media. The example I found particularly amusing was this from the NYT:

In the worst case reported, a chest tube was inserted into the wrong lung — the healthy one — and it collapsed, killing the patient.

I'm just an internist but I didn't know there was a correct lung to insert a chest tube into. The pleural space is quite far enough, thanks.